II.

WEEK 3 MODULE: LEARNING CONTENT

Pregnant woman, newborn, children and older adults belong to the special client group. These group
are one of the major focus of the nursing practice as to have a healthy adults, one must have a
healthy children. Health assessment of a childbearing woman helps to recognize and avoid health
problems that might occur before, during and after birth. Nurses works closely with expecting parents
during pregnancy. Newborn assessment immediately start the moment he/she is delivered. The
doctor or the nurse must immediately gently clears mucus and other material from the mouth and
throat in able for them to take a breath. As ageing cannot be prevented, care of the elderly requires
more time, resources and energy than younger patients.

Health Assessment in a Childbearing Woman:

During pregnancy, physiologic and anatomic changes occur. These changes are influenced by
estrogen and progesterone which are the hormones of pregnancy.

SKIN, HAIR and NAILS:

Hormonal changes results in different changes in the Integumentary system. Estrogen, Progesterone
and melanocyte-stimulating are the primary hormones involved in these change. Hyperpigmentation
occurs and mostly noted in the abdomen. Some of the changes noted during pregnancy are: (1)Linea
nigra, a dark streak down the midline of the abdomen, (2) Chloasma also known as mask of
pregnancy which is a blotchy brownish hyperpigmentation, over the forehead, cheeks and nose, (3)
Striae gravidarum or the reddish purple stretch marks on the abdomen, breast, thighs and upper arms
occur.

EARS and HEARING:

Pregnant woman may experience a sense of fullness in the ears, earaches and decreased hearing
because of the increase vascularity of the tympanic membrane and blockage of the eustachian
tubes.

BREASTS:

Due to the increase in estrogen and progesterone, there is a notable changes in the mammary
glands. Breast size increases and may become tender. Nipples become more pronounced. The
areola become darker in color and superficial veins become prominent. Hypertrophy of Montgomery’s
occur and colostrum may leak from the breast.

HEART:

Cardiovascular changes also occurs, blood volume circulating in the system increases, plasma
increases and the total red blood cell volume also increases by approximately 40% to 50%. This will
lead to an increase work load of the heart and will lead to an increase in size of 1 to 1.5 cm and heart
rate is elevated by 10 to 15 beats per minute. Physiological anemia occurs and iron requirements are
increased.

THORAX and LUNGS:

The client respiratory pattern changed during pregnancy. Diaphragm is elevated because of the
enlarge uterus. Shortness of breath is a common experienced. Oxygen requirements increases by
approximately 15 to 20%.

RENAL SYSTEM:

The expanding uterus exert pressure to the bladder, kidney and ureters. This lead to frequency of
urination which increases in the first and third trimester. Decreased bladder tone may occur and is
due to an increase in progesterone and estrogen levels.

GASTROINTESTINAL SYSTEM:

The enlarging uterus applies pressure and displaces the small intestines. Nausea and vomiting may
occur as a result of the secretion of human chorionic gonadotropin which subsides typically on the
third month. Increase in progesterone production or pressure of the uterus trigger decrease gastric
motility and may lead to poor appetite and constipation. Alteration of taste and smell may also
happen.

REPRODUCTIVE SYSTEM:

The uterus enlarges and increased in mass from approximately 60 to 1000 grams as a result of
hyperplasia and hypertrophy. The size and number of blood vessels also increases. Irregular
contractions occur typically beginning 16 weeks of gestation.

The cervix becomes shorter, more elastic and larger in diameter.

The ovaries secrete progesterone for the first 6 to 7 weeks of pregnancy and the maturation of new
follicles is blocked which lead to the cessation of ovum production.

There is a thickening and hypertrophy of the vaginal muscles and an increase in vaginal secretion is
experienced which is usually thick, white and acidic.

PSYCHOLOGICAL MENTAL CHANGES:

Ambivalence which is a simultaneous and contradictory attitude or feeling occur early in pregnancy.
Acceptance leads to the need of task accomplishment such as accepting the pregnancy, identifying
with the mothering role, solidifying her relationship with her partner, establishing a relationship with
her unborn infant, and preparing for her birth experience.

HEALTH ASSESSMENT: COLLECTING SUBJECTIVE DATA

A complete health history is necessary in able to provide high quality care for the pregnant client.
The first pre-natal visit is focused on collecting baseline data about the client and her partner, and
identification of risk factors.

Childbearing Woman Assessment Guide

BIOGRAPHICAL DATA

Question Rationale

What is your name, address, and telephone number?

How old are you? What is your date of birth? Note if the client is
a male or female

What is your marital status?

What is your educational level and where are you employed?

HISTORY OF PRESENT HEALTH CONCERN

What was your normal weight before pregnancy? Has your

weight changed since a year ago? How much weight have you
gained since your last menstrual period?

Have you ever had fever, chills, except with cold since your last
menstrual cycle?

Is your nose often stuffed up when you don’t have cold? Have
you experience more frequent nosebleeds while pregnant?

Do you have any trouble with your throat? Do you have a cough
that hasn’t gone away, or do you have frequent chest infections?

Do you have nausea or vomiting that doesn’t go away? Is your

thirst greater than normal?

Do you ever have bloody stools? Do you have any change in

bowel habits? Do you have difficulty when trying to have bowel
movement?

Do you experience a burning sensation while urinating?

Do you have vaginal bleeding, leakage of fluid or vaginal

discharge?

Have you lost interest in eating? Do you have trouble falling

asleep or staying asleep? Do you ever feel depressed or feel like
crying for no reason? Are problems at home or work bothering
you? Have you ever thought of suicide? Have you ever had
professional counselling?

Have you noticed breast pain, lumps or fluid leakage?

Have you thought about breast-feeding or bottle feeding your

infant?

Are there any problems or concerns you may have that we

haven’t discussed yet?

PERSONAL HEALTH HISTORY

Will you be 35 years or older when the baby is born? Are you and
the baby’s father related to each other?

List the number of times you have been pregnant, beginning

with the first pregnancy.

Describe your previous pregnancies including the child’s name,

birth date, birth weight, sex, gestational age, type of delivery (is
CS, discuss the reason).

Did you experience any complication during pregnancies?

Describe any neonatal complications such as birth defects,

jaundice, infection, or any problems within the first 2 weeks of
life.
Describe any perinatal or neonatal losses, including when the
loss occurred and the reason for the loss, if known. Have you
ever had a child die in the first year of life?

Discuss previous abortions (spontaneous or elective), including

proce- dures required and gestational age of fetus. Have you had
two or more pregnancies that ended in miscarriage?

Have you ever had a hydatidiform mole (molar pregnancy)?

Have you ever had a tubal (ectopic) pregnancy (pregnancy

outside of the uterus)?

Do you have regular periods? When was the first day of your last
menstrual period? Was this period longer, shorter, or normal?
Have you had any bleeding or spotting since your last period?
Are your periods usually regular or irregular?

Describe the most recent form of birth control used. If you’ve

used birth control pills in the past, when did you take the last
pill?

Have you had any difficulty in getting pregnant for more than 1
year?

Have you ever had any type of reproductive surgery? Have you
ever had an abnormal Pap smear? Have you ever had any
treatment performed on your cervix for abnormal Pap smear
results? When was your last Pap test, and what were the results?

Do you have a history of having any type of sexually transmitted

infections (STIs) such as a chlamydial infection, gonorrhea,
herpes, genital warts, or syphilis? If so, describe when it occurred
and the treatment. Does your partner have a history of STI? If so,
when was he treated?

Do you have a history of any vaginal infections such as bacterial

vaginosis, yeast infection, or others? If so, when did the last
infection occur and what was the treatment?

Do you know your blood type and Rh factor? If you are Rh

negative, do you know the Rh factor of your partner?

Have you ever received a blood transfusion for any reason? If so,
explain reason and provide date.

Do you have a history of any major medical problem (e.g., heart

trouble, rheumatic fever, hypertension, diabetes, lung problems,
tuberculosis, asthma, trouble with nerves and/or depression,
kidney disease, cancer, convulsions or epilepsy, abnormality of
female organs [uterus, cervix], thyroid problems, or hearing loss
in infancy)?

Do you have diabetes?

Have you had twins or multiple gestation?

Do you have a history of medication, food, or other allergies? If

so, list the allergies and describe the reactions.

Have you ever been hospitalized or had surgery (not including

hospitalizations or surgery related to pregnancy)? If so, discuss
the reason for the hospitalization or surgery, the date, and if the
problem is resolved today.
Are you currently taking any medications (either prescription or
nonprescription) or have you taken any since you have become
pregnant? If so, list the medication, the amount taken, the date
you started taking it, and the reason for taking it.

Are your immunizations up to date? Have you received the

influenza immunization this year?

FAMILY HISTORY

Do you have a child with a birth defect? Do you have any type of
birth defect or inherited disease such as cleft lip or cleft palate,
club- foot, hemophilia, mental retardation, or any others? Are
there any members in your family with a birth defect, inherited
disease, blood disorders, mental retardation, or any other
problems? What is your ethnic or racial group: Jewish,
Black/African, Asian, Mediterranean (e.g., Greek, Italian), French
Canadian?

Has anyone in your family (grandparents, parents, siblings,

children) had rheumatic fever or heart trouble before age 50
years?

Has anyone in your family had lung problems, diabetes,

tuberculosis, or asthma?

Has anyone in your family been diagnosed with any type of

cancer? If so, what kind?

LIFESTYLE AND HEALTH PRACTICES

Since the start of this pregnancy, have you had drinks containing
alcohol almost every day or frequently?

Do you smoke? If so, how much do you smoke per day?

Have you used cocaine, marijuana, speed, or any street drug

during this pregnancy?

Does anyone in your family consider your social habits to be a

problem? Do your social habits interfere with your daily living? If
so, please explain.

What is a normal daily intake of food for you? Are you on any
special diet? Do you have any diet intolerances or restrictions? If
so, what are they?

Do you eat lunchmeats or unpasteurized milk products?

Do you currently take any vitamin supplements? If so, what are

they?

Do you exercise daily? If so, what do you do and for how long?

Have your normal daily activities or exercise ever had a negative

impact on your previous pregnancies? If so, please discuss.

Do you perform any type of heavy labor (lifting > 20 lb) while
work- ing or while at home? If so, please describe.

Are you easily fatigued? Do you require more sleep than 8 hours/
day? Do you get fatigued with your daily routine of work/family
life? Do you get fatigued by performing daily household chores,
such as cleaning, running errands, etc? If so, please describe.
What are your normal sleeping patterns?
 Do you frequently have rest periods? If so, for how long?

Have you or your partner ever worked around chemicals or

radiation? If so, please explain. Are you exposed to an excessive
amount of tobacco smoke daily?

Do you have a cat? If so, are you exposed to cat litter or cat
feces?

What is your occupation?

What are your typical daily activities? Who do you interact with
each day? Do you find work, activities, and the people you
encounter in them supportive or stressful?

Discuss your feelings about this pregnancy. Is the father of the

baby involved with the pregnancy? How does your partner feel
about the pregnancy? To what degree do you feel that the father
of the baby will be involved with the pregnancy (e.g., not
involved, interested and supportive, full caretaker of the
pregnancy)?

What type of support systems do you have at home? Who is

your primary support person? List the people living with you
including their names, ages, relationship to you, and any health
problems that they may have. Are they aware of your
pregnancy?

How have you introduced this pregnancy to any siblings? What

are their reactions regarding this pregnancy? Do you plan to
involve the siblings in any type of education program to enhance
the attachment process for the newborn?

Has anyone close to you ever threatened to hurt you? Has

anyone ever hit, kicked, choked, or physically hurt you? Has
anyone ever forced you to have sex?

What is your partner’s highest level of education? What is your

partner’s occupation or major activity? Does your partner
consume alcohol? If yes, how much alcohol does your partner
use daily? List type and amount. Does your partner smoke? If
yes, how often does your partner smoke? List amount and
frequency. Does your partner use illicit drugs? If yes, how often
does your partner use illicit drugs? List drug type, amount, and
frequency.

PHYSICAL ASSESSMENT:

Assessment Procedure Normal Findings Abnormal Findings

Blood Pressure

Pulse Rate

Temperature

Height and Weight

Breast

Abdomen

Fundal Height
 Fetal Position

Assessment of the Abdomen:

https://www.youtube.com/watch?v=G-6x6Po5orc

Computation of LMP and EDC

https://www.youtube.com/watch?v=N0iqVBX5F9s

NEWBORN HEALTH ASSESSMENT:

Babies are considered neonates from birth to the end of the first month. Infants are babies from 1
month of age to 1 year. An infants basic task involves survival, which requires breathing, sleeping,
sucking, eating, swallowing, digesting and eliminating.

At birth, most babies weight from 2.5 kg to 4.0 kg (2500g to 4000g). Infant will usually loose 5% to
10% of their weight just after birth because of fluid loss which is normal and regain the weight in
about a week. After several days, babies usually gain 150g to 210g weekly for 6 months.

The average length of a newborn is 44cm to 55cm. Head Circumference is 33cm to 35 cm with the
chest circumference of 31cm to 33cm which is 1cm to 2 cm less the head circumference.

APGAR SCORE is used to assess babies immediately after birth. This provide a numeric indicator of
the baby’s physiologic capacities to adapt to extrauterine life. In APGAR scoring system, each of the
five signs is assigned a maximum of 2 so that a maximum achievable score is 10. A score under 7
indicates that the babyis having difficulty and a score of 4 indicates that the baby’s condition is critical
and needs immediate medical attention. APGAR scoring is carried out 60 minutes after birth and is
repeated in 5 minutes.

APGAR SCORING VIDEO:

https://www.youtube.com/watch?v=cQKaTCMFjwc
NEWBORN REFLEXES:

There are different reflexes present in all normal newborns and mostly disappear within a few months
after birth. Absence of reflex at birth or persistence of a reflex past a certain age may indicate a
problem with central nervous system function.

1. ROOTING REFLEX – to elicit touch the newborn’s upper or lower lip or cheek with a gloved finger
or sterile nipple and observe that the newborn should turn or move the head toward the stimulated
area an open the mouth. This disappears by 3-4 months.

2. SUCKING REFLEX – Place a gloved finger or a nipple in the newborn’s mouth and note the
strength of the sucking response. This disappears at 10-12 months.

3. PALMAR GRASP REFLEX – Press your finger against the palmar surface of the newborn’s hand
from the ulnar side. It should be a strong grasp and the newborn may even be able to be pulled to a
sitting position. This disappears in 3 - 4 months.

4. PLANTAR GRASP REFEX – When you touch the ball of the newborn’s foot,the toes should curl
downward tightly. This disappears in 8 -10 months.

5. TONIC NECK REFLEX – The newborn should be placed in a supine position. Turn the head to one
side, with the newborn’s jaw at the shoulder. This is observed when the arm and leg on the side to
which the head is turned extend and the opposite arm and legs flexed. This reflex disappears in 4-6
months.

6. MORO / STARTLE REFLEX – this is a response to a sudden stimulation or an abrupt change in

position. This reflex disappear by 3 months.

7. BABINSKI REFLEX – Hold the newborn foot and stroke up the lateral edge and across the ball of
the foot. If fanning of the toe is exhibited a positive Babinski reflex is noted. This disappears within 2
years.

8. STEPPING REFLEX – Hold the newborn upright from behind, provide support under the arms and
let the newborn’s feet touch the surface. The newborn will provide a stepping in one foot and the
other in a walking motion response. This disappears in 2 months.

ELDERLY HEALTH ASSESSMENT

As the person ages, a number of physical changes occurs which may or may not be visible. In
general lean body mass is reduced and fat issue increases until the age of 60. There is an obvious
changed in the integumentary system. The skin become more dry and fragile, the hair loses color, the
fingernails and toenails become thicker and brittle. Response to these changes vary among
individuals.
NORMAL PHYSIOLOGICAL CHANGES ASSOCIATED WITH AGING:

INTEGUMENTARY

Increased skin dryness

Increased skin pallor

Increased Skin fragility

Progressive wrinkling and sagging of the skin

Brown “age spots” (lentigo senilus on exposed body

parts

Decrease perspiraton

Thinning and graying of scalp, pubic and axillary

hair

Slower nail growth and increased thickening with

ridges

NEUROMUSCULAR

Decreased speed and power of skeletal muscle

contractions.

Slowed reaction time

Lost of height (stature)

Osteoporosis

Joint stiffness

Impaired balance

SENSORY/PERCEPTUAL

Loss of visual acuity

Increased sensitivity to glare and decreased ability

to adjust to darkness

Partial or complete lossy white circle around the

periphery of the cornea (arcus senilis)

Progressive loss of hearing

Decreased sense of taste, especially sweet

sensation at the tip of the tongue
Decreased sense of smell

Increased threshold for sensations of pain, touch

and temperature

PULMONARY

Reduce cardiac output and stroke volume

Reduced elasticity and increased rigidity of arteries

Increase in blood pressure

Orthostatic hypertension

GSTROINTESTINAL

Delayed swallowing time

Increased tendency of indigestion

Increased tendency of constipation

URINARY

Reduced filtering ability of the kidney and impaired

renal function

Less effective concentration of the urine

Urinary urgency and urinary frequency

Tendency for a nocturnal frequency and retention of

residual urine

GENITALS

Prostate enlargement (benign) in men

Multiple changes in woman

KATZ ACTIVITY OF DAILY LIVING is a tool used to detect problems in performing Activities of Daily
Living (ADL) and to plan care accordingly.

LAWTON SCALE FOR INSTRUMENTAL ACTIVITIES OF DAILY LIVING asses a person’s ability to
perform task such as using a telephone, doing laundry, shopping, housekeeping etc.
REFERRENCES:

Berman, A., Snyder, S., Frandsen, G., Kozier (2016). Kozier and Erb’s Fundamentals of Nursing
Concepts, Process and Practice (10th Edition)

© 2014 Keith Rischer, RN, MA, CEN, CCRN/http://www.keithrn.com/downloads/ clinical-

reasoning.questions-develop-nurse-thinking/

American Nurses Association. The Nursing Process

Weber, J., Kelly, J., Health Assessment in Nursing Fifth Edition

https://www.youtube.com/watch?v=cQKaTCMFjwc

https://www.youtube.com/watch?v=N0iqVBX5F9s

https://www.youtube.com/watch?v=G-6x6Po5orc

JAKE M. ZAMORA, RN, MAN

Clinical Instructor